Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Friday, October 05, 2007

Vital signs my friends. Vital signs. If I had not looked at this young man's vital signs I would have let him sit for a while with his chest pain. After all he was an 18 year old without trauma. What's the worst it could be? The nurse did document a pulse of 140 but somehow triaged him to a low category. I saw the pulse rate and went back to see this young man who was looking quite ill.

Now the dogma is that you never want to diagnose a tension pneumothorax by Xray but that is in fact what happened here. Without trauma it was not apparent to me to even think about it and he was maintaining his oxygen saturations. I did suspect a pneumothorax in this tall thin kid who smoked but I did not expect this.

As you can see from the first film there is a very clear looking right lung field. The busy-looking hilar area on the right near the middle is his right lung, fully collapsed, and, if you look closely you can see the trachea deviated into the left lung field.

As soon as I saw the Xray we moved him to a critical bed and I stuck a 14 angiocath between the 4th and 5th ribs on the right. There was no dramatic rush of air so I think this was early tension, but when I put in the chest tube (seen clearly in the mostly re expanded left lung apex) I did get a nice rush of air.

Concerningly, this young man's lungs do not appear normal after the chest tube so suspicion is raised for an underlying undiagnosed disorder like alpha 1 antitrypsin deficiency. Vital signs people. 18 year olds with chest pain sometimes have a life threatening cause and we can not miss them.

20 comments:

Btw, Why did you choose the 4th intracostal space? All my instruction typical mandates the second intracostal?? Also, was there any dramatic trachea deviation visible externally? Since I dont typically get Xray available to me (wry grin) I'm wondering how late and how pronounced the tracheal deviation usually presents.

doc h, basically i could have darted him anywhere and been fine. there has been some change in the past 5 years in the rec. for darts and chest tubes. it used to be dart mid clavicular line, now it's mid axillary, same place as the chest tube. i don't know the whys and wherefores and don't really care. i just do what my surgeons want and now they want it in the mid axillary line, 4th of 5th space. in larger individuals you may need to just go wherever you can without biopsying the liver or diaphragm. cheers.

25 years ago, when we were first learning needle decompression, we had the choice of mid-clav or mid-ax, 2nd or 5th respectively, as you stated. Then, because it was assumed that all ptx patients in the field would be upright, the mid-clav site was decided upon (air rises, flaccid lung parynchema would sink inferiorly and posteriorly, etc.)

Just a question, and you may have answered it ("I think this was early tension"), but with no real rush of air on the needle decomp, could we agree this was complete but not yet tension? The trachea is deviating toward the affected side, and the mediastinum appears to be in the expected place on CXR.

You may think this a difference without a distinction, but I have this argument with my students all the time - decompress when you can make the case for tension (tympanic percussion, trachea/mediastinum deviating away from the affected side, notable JVD, etc.) They (paramedic students) want to stick a needle in every chest with decreased lung sounds.

dear patrick, thanks for your comment. as you know, especially in non traumatic pneumothorax, the evolution to tension may or may not occur. i think this guy was putting just a bit of air into the pleural space with each breath. he had been symptomatc for three days so i think this was definitely a continuum and i think he would have died from it but probably not for hours. early tension, soon to be tension? certainly complete.cheers.

i'm curious as well and will remain so. one of the vagaries of emergency medicine and all. if i run into the surgeon and he remembers the patient (from last year) i'll see if he got that diagnosis... would be a first for me.

I agree with Patrick. Was he hypotensive? Elevated pulse could well have been from pain. General rule says spontaneous ptx do not produce tension and you think this guy had it for 3 days..I say this exact xray last month. 100% spont ptx in a young guy. You don't see many 100% spont ptx!

Oldfart, he was 91% on room air, probably on the steep part of the curve. nonetheless, the airway was shifted. call it what you will, he was sick.

Dear Lynn, a dart is simply a needle with a cath tip. you put the needle between the ribs, being careful to enter the pleural space just above a rib, and take the needle out leaving the catheter in place. a temporizing measure while you get set up for the chest tube. a chest tube is a bit smaller in diameter than a garden hose and has to be placed in the same manner as the 'dart' but aimed toward the head and apex of the lung. it then has to be sewed in place and connected to water suction apparatus that will provide continuous mild negative pressure to the pleural cavity. chest tubes, i'm told, hurt a wee bit and i use lots of lidocaine and generous ammounts of drugs when able. sometimes you just have to do it immediately as in the case of a tension pneumothorax. this case was a bit weird in that, as you can see, there is some debate as to whether his collapsed lung was under increasing internal pneumatic pressure (tension) or not (spontaneous pneumothorax without tension). bottomw line, he needed a chest tube quickly.

911, is it safe for me to assume that docs make an incision with a scalpel and shove the garden hose through the ribcage only in emergency situations? Otherwise, they dart? Or is this a matter of preference?

I've only seen the scalpel method, and those were emergencies - hence my question.

Note to self: never, ever, under any circumstances, allow your lung to fold up like a cheap napkin...

I know I probably sound like a real moron. Trust me; my writing is far more realistic and intelligent than what I'm projecting here. At least that's what my doc readers tell me.

dear lynn, i appreciate your questions. an angiocath is a temporizing measure. some slight pneumothoraces may be simply followed with serial chest Xrays to make sure they resolve. there is lots of debate as to how big the pneumothorax needs to be to require the 'garden hose' method. though, in combat situations, some case reports exist of treatment with the needle decompression and aspiration of air alone, these are rare. other docs please add as you see fit. cheers.

I'm not a doc but I've seen quite a few patients that presented with a pneumothorax without injury. In all the cases they had one of two underlying diagnosis; either AIDS or Marphan's syndrome. I'm am unaware of what alpha 1 antitrypsin deficiency is. Would you mind enlightening me?

What is Alpha-1? Alpha-1 Antitrypsin Deficiency, or Alpha-1, is an inherited genetic condition which predisposes you to the development of certain diseases. Most commonly these are lung disease and liver disease. Many persons diagnosed with Alpha-1, however, never develop any disease associated with Alpha-1. Individuals with Alpha-1 have lower than normal levels of a protein in the blood called alpha-1 antitrypsin or AAT.

Not sure how long the angiocath was, but there is potentially 2cm or more of tissue between the skin and pleura; if you don't get a rush of air, it doesn't meant there's not a tension, it may mean your angiocath's not long enough. They make long ones, 3-4cm I think. Used to carry one around, but then used it and haven't replaced it.